Child battery syndrome Flashcards
Categories of child abuse
- Physical abuse
- Sexual abuse
- Psychological or emotional abuse
- Neglect
define physical abuse
non-accidental injury
may be key to diagnosis of child abuse
External exam – bruises, abrasions, burns may indicate possibility of internal injuries, including underlying fractures
Whats something to remember with injuries?
Bone injuries rarely exist in isolation, without some evidence of soft tissue injuries
Physical abuse – injury characteristics
- Injuries in various stages of healing, not only fractures, but also bruises
- Multiplanar injuries, i.e. injuries that do not make anatomical sense
- Patterned injuries, e.g. hand marks, belt marks
- Locations typical of assault – look for injuries in regions normally well protected, e.g. face, neck, upper arms and upper legs, perineum
% of childhood fractures result from abuse
30% of childhood fractures result from abuse
In children < 1 year old, as much as __% of fractures may be inflicted deliberately
75
Most physically abused children are
< 2 years old
children are < 1 year old
About 1/3 of physically abused
Occult
hidden concealed
Children homeside occurances
Most homicides of children occur in first 2 years of life
What are the common first year injuries?
First year: mainly (85-90%) head injuries
What are the common second year injuries?
Second year: head injuries about 50%, blunt abdominal injuries about 50%
What is something to be aware of when it comes to looking at possible child abuse cases?
There may have been multiple episodes so look for other injuires
Mimics of child abuse
- Congenital indifference to pain
- Congenital sensory neuropathy
- Congenital conditions such as meningo-myelocoele
- Acquired spinal cord injuries
- Acquired cerebral injuries
Radiologic evidence
often x-ray examination may yield clues to patterns of abuse
Radiologic skeletal changes may underlie visibly obvious cutaneous injuries, but are evident long after the cutaneous injury has resolved
Inconsistency of story and injury
- injuries may be inconsistent with child’s age
- injuries may be disproportionate to their purported cause
- injuries may be inappropriate to the purported mechanism of injury
what are pathognomonic clues for child abuse (pathognomonic = specifically distinctive, characteristic)
Multiple fractures at multiple sites in multiple stages of healing seen on X-rays
Most common sites of fractures (from most to least frequent):
- long bones of appendicular skeleton
- skull
- ribs
Physical abuse of a magnitude sufficient to fracture bones usually occur in what kind of bone?
younger and hence smaller children – smaller bones are easier to deliberately fracture
About half of abused children have what kind of fractures and how many and where?
a single fracture, usually a tranverse (direct, angulation, or tension pattern) fracture, or a spiral (twisting or rotatory pattern) fracture – humerus, femur, tibia are most common sites. The direction of a fracture is of less importance than the actual site of the fracture and the age of the child.
What are common presentations in an abused child?
Fracture(s) of skull and dehiscence of skull sutures, together with fractured long bone shafts
Fractures at ____ (ex.___) should always be questioned
unusual sites (lateral ends of clavicles, ribs, scapula, sternum, spine)`
Why is the difference between adult and child bone important?
render children’s bones susceptible to different patterns of fracture
Primary agent of endochondral ossification
physis, or growth plate, or epiphyseal plate
Injury patterns seen in infants are much different from those seen in older children, as result of
- mechanism of actual injury in the two age groups
- different skeletal responses to the applied forces as a result of skeletal differences (changes in bone structure at microscopic and macroscopic level)`
Infancy (first year): most common injuries
ribs and metaphyseal regions
Childhood (older than one year): most common injuries
long bone fractures, then skull and rib fractures
Holding child or infant by thorax and shaking tends to lead to what?
“classic metaphyseal lesions” (CMLs) in arms and legs, usually bilaterally symmetrical
Holding infant or child by an arm or leg and shaking or throwing the infant/child may lead to what?
unilateral metaphyseal lesions or focal long bone injuries
Diagnosis of child abuse by skeletal indicators
- Highly specific fractures
2. Specific combinations of fractures
More often, rather than a finding of a highly specific fracture, it is the combination of what that allows diagnosis of abuse?
a (1) the fracture type, (2) the history, and (3) the developmental stage of the child
Shaking of infant/child may lead to multiple CMLs. Most common sites for this injury is?
knee, ankle, distal humerus
What occurs in a CML fracture?
Actual lesion is a mineralized disc of metaphyseal bone that has been fractured from primary spongiosa of metaphysis.
Twisting, either deliberate or accidental, of femur or humerus may lead to what?
transverse, oblique, or spiral diaphyseal fractures
What is very important when determining accident from abuse
history of injury
Relationship in frequency between shaft and CML fractures?
Shaft fractures are more commonly seen in abuse than are CMLs, but are less specific for abuse
Femoral shaft fracture < 1 year of age?
very suggestive of abuse
Humeral shaft fracture < 1 year of age
considered diagnostic of abuse
In absence of any history of trauma, presence of what is suspicious for abuse, particularly in infant not yet walking?
oblique or spiral shaft fracture of femur or humerus
Children who are shaken violently are often held by arms or legs – accounts for most of classic radiologic long bone hallmarks of child abuse:
- metaphyseal fractures
- epiphyseal separation
- subperiosteal new bone formation along shafts of long bones
Rib fractures and child abuse?
3rd most common type of fracture in abused children; tend to be multiple in number
Why is it rare for ribs of infants and young children to be fractured in everyday play?
thoracic cage is quite elastic – usually requires severe direct impact type of trauma
Rib fracture < 2 years of age is considered what until proven otherwise?
abuse
What is not a valid excuse when discussing rib fractures in kids?
CPR
Describe torus fractures in the ribs
buckling of cortex due to compression; amount of buckling may be subtle; microfractures allow buckling to occur without overt fracture line
Lateral rib fractures usually are due to what?
anteroposterior compression of chest, often by a punch or blow with a blunt object when infant or child is on a flat surface, or slamming chest of child into an inanimate object - rib is flattened anteroposteriorly
Sternal and chondral fractures
significant blow to anterior central chest may fracture sternum and/or costal cartilage, as well as cause a separation of costochondral junction; rare to see these injuries in children otherwise, except in high impact trauma, e.g. MVA
Common skull fracture patterns in abuse?
- depressed fractures
- complex fractures
- wide fractures
- multiple fractures
Common skull fracture patterns in accidents?
linear skull fractures
Relationship between brain and skull injuries?
Skull can be fractured without an underlying brain injury, and brain can be injured without an overlying skull fracture; lack of skull fracture therefore does not have any predictive value as far as deciding whether an infant has sustained a brain injury as a result of abuse
Most forensic pathologists feel that a child falling from a distance of _____ will not sustain a brain injury
about 1 metre or less
Extent of brain injury sustained by child relates to what?
amount of energy absorbed by brain, not by skull
How can you get brain injuries without skull injuries?
Brain and skull each have their own inertial properties – hence when head is either suddenly struck with a moving object, or stuck against an immoveable object, brain moves independently within the cerebrospinal fluid of the skull
Linear skull fracture occurs how?
when tensile strength of skull is exceeded – begins at inner table in inbent area (impact point) and at outer table of outbent area (increased tensile strength)
Linear fractures are created how?
by relatively low velocity forces of high mass
Coup injury
direct injury to brain by inward bending of skull
Contrecoup injury:
injury of brain on side opposite to site of external impact injury – can be due to focal cavitation as well as direct contact of opposite side of brain with skull
How can a depressed skull fracture be caused?
High velocity forces with small mass may actually exceed tensile of skull at impact point
